Understanding RA Flares

New research aims to measure the severity and impact of RA flares, and identify what may trigger them.

By Susan Bernstein

Over a decade ago, immunologist Kathy Molnar-Kimber was investigating gene therapy for cancer at the University of Pennsylvania in Philadelphia, but struggled with devastating flares of her rheumatoid arthritis.

“At the time, if you touched my left arm, it hurt so badly that it felt like exploding grenades for hours,” says Molnar-Kimber.

Biologic response modifiers and corticosteroids did not successfully control her inflammation and flares. So she tried to look “outside the box” to identify self-management strategies and complementary therapies to alleviate her pain. Techniques like praying, regular hydration, herbal treatments and vitamins and avoiding harsh environmental chemicals like insect sprays seemed to lessen the impact or duration of her flares.

How to Measure a Flare

Flares – acute episodes of various RA symptoms, including pain, inflammation, stiffness, fatigue and impaired physical function – vary in intensity, duration and impact on the ability to perform daily tasks like typing, dressing or driving. Finding better ways to measure flares’ intensity and identify possible triggers are areas that many RA researchers, including Molnar-Kimber, are now exploring.

People with RA may struggle to communicate effectively about their flares to their rheumatologists, making treatment a guessing game. Identifying the potential triggers of flares, as well as ways rheumatologists may better quantify and categorize these episodes, may facilitate more effective communication and treatment, says Thasia Woodworth, MD, a rheumatologist and nephrologist currently researching flares at the University of California, Los Angeles, Medical Center.

While working on a project to develop rheumatic disease toxicity criteria in 1999, Dr. Woodworth and other researchers realized that there was no standard measurement to quantify RA flares. Yet patients often report flares in clinical trials that study drug toxicity and effectiveness.

“We need to be able to measure reliably, consistently and in a standard fashion all the adverse events and effects in these clinical trials,” says Dr. Woodworth. To understand flares and their impact better, researchers and clinicians alike need reliable measurement tools.

Defining Flares

In 2006, OMERACT’s (Outcome Measures in Rheumatology, an international research organization) Drug Safety Working Group chartered an RA Flare Definition Working Group to develop a standard definition of RA flares. The goal is to create a patient questionnaire to allow rheumatologists to detect, measure and define the intensity of RA flares and, based on the results, suggest proper treatment.

Over a decade ago, immunologist Kathy Molnar-Kimber was investigating gene therapy for cancer at the University of Pennsylvania in Philadelphia, but struggled with devastating flares of her rheumatoid arthritis.

“At the time, if you touched my left arm, it hurt so badly that it felt like exploding grenades for hours,” says Molnar-Kimber.

Biologic response modifiers and corticosteroids did not successfully control her inflammation and flares. So she tried to look “outside the box” to identify self-management strategies and complementary therapies to alleviate her pain. Techniques like praying, regular hydration, herbal treatments and vitamins and avoiding harsh environmental chemicals like insect sprays seemed to lessen the impact or duration of her flares.

How to Measure a Flare

Flares – acute episodes of various RA symptoms, including pain, inflammation, stiffness, fatigue and impaired physical function – vary in intensity, duration and impact on the ability to perform daily tasks like typing, dressing or driving. Finding better ways to measure flares’ intensity and identify possible triggers are areas that many RA researchers, including Molnar-Kimber, are now exploring.

People with RA may struggle to communicate effectively about their flares to their rheumatologists, making treatment a guessing game. Identifying the potential triggers of flares, as well as ways rheumatologists may better quantify and categorize these episodes, may facilitate more effective communication and treatment, says Thasia Woodworth, MD, a rheumatologist and nephrologist currently researching flares at the University of California, Los Angeles, Medical Center.

While working on a project to develop rheumatic disease toxicity criteria in 1999, Dr. Woodworth and other researchers realized that there was no standard measurement to quantify RA flares. Yet patients often report flares in clinical trials that study drug toxicity and effectiveness.

“We need to be able to measure reliably, consistently and in a standard fashion all the adverse events and effects in these clinical trials,” says Dr. Woodworth. To understand flares and their impact better, researchers and clinicians alike need reliable measurement tools.

Defining Flares

In 2006, OMERACT’s (Outcome Measures in Rheumatology, an international research organization) Drug Safety Working Group chartered an RA Flare Definition Working Group to develop a standard definition of RA flares. The goal is to create a patient questionnaire to allow rheumatologists to detect, measure and define the intensity of RA flares and, based on the results, suggest proper treatment.

Dr. Woodworth, working under UCLA Medical School rheumatologist Daniel Furst, MD, and 300 other rheumatology researchers in various countries are conducting focus groups of RA patients to develop ways to measure flares. Their hope is that the final measurement questionnaire tool will be approved at the OMERACT global meeting in 2014.

At a series of focus groups held in five countries, these researchers asked people with RA to talk about their flares, and have developed a pilot questionnaire that may one day be used by rheumatologists to measure flares. Questions focus on a description of flare symptoms, self-management strategies and rating the impact of flare symptoms on daily activities.

After gathering more than 1,000 questionnaires, Dr. Woodworth has noticed that stiffness is one of the most common problems people with RA develop during flares. “It’s hard to measure stiffness by duration, because it’s highly variable. But having patients report the severity of their stiffness on a 10-point scale is really useful,” she says. Patients don’t just report classic morning stiffness during flares. They also experience stiffness at other times of day and after sitting or strenuous activity.

What Triggers Flares?

Molnar-Kimber, who left her university research position in 2002 to focus on independent research on RA flares, also has been querying people with RA about their flare experiences through a web-based questionnaire. She has gathered more than 500 responses looking at the potential triggers of RA flares and how they may impact the person’s joints and function, and has published her findings in peer-reviewed journals.

Common triggers seem to be sensitivity to particular foods, falls or physical traumas, exposure to environmental toxins like cigarette smoke or industrial pollution, and infections, she says.

Categorizing Flares

Currently, RA flares are broken into four categories based on duration and impact, Dr. Woodworth says. Mild flares may last a week or less, and be successfully treated with over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen, and basic self-management strategies like ice or rest.

Moderate flares may last longer, and require an opiate analgesic and activity restriction for up to two weeks. Severe flares are disabling, requiring time off from work and highly restricting activities, plus the need to take an opiate or corticosteroids to alleviate it.

The most devastating RA flare is what Dr. Woodworth calls “life-interrupting.” This type of flare doesn’t resolve with standard treatment and may requiring the rheumatologist to reconsider the entire disease-management approach for that patient. “Nowadays, we are lucky to have lots of treatments to work with in RA. Nevertheless, during flares, joint damage can occur, and disability.”

Learning About Flares from People With RA

Dr. Woodworth says the questionnaires indicate a shift from looking at lab test results to actually gathering data from RA patients who are, after all, the greatest source of knowledge about flare causes and impacts.

“We are developing a deeper appreciation for flares, what precipitates it and what can manage it better,” Dr. Woodworth says.

She’d like to see the approved tool posted online, so patients may self-test and learn when a flare’s severity requires a call to their rheumatologist, or when they can self-manage it successfully. “This is a tool for patients. It’s intended to facilitate communication in a more timely fashion and help patients better understand their flares.”